Patient: 52-year-old African-American male. Chief Complaint: Severe abdominal pain and difficulty eating. History of Present Illness: The patient presented to the emergency room (ER) with severe abdominal pain. Approximately 3 months prior to his visit, the patient stopped taking his metformin for diabetes and monitoring his glucose. For the next 3 months, the patient experienced rapid weight loss, a rash on the center of his tongue, genital skin sloughing, and sharp lower back pain. The patient then decided to resume his medication. Subsequently, the rash on his tongue cleared, the sloughing decreased but did not clear, and his back pain subsided. The patient began experiencing occasional pain when swallowing food, but dismissed the symptoms. On the morning prior to his ER visit, when the patient swallowed food he had mild discomfort in the upper esophagus and it felt as though food was lodged in his esophagus after the meal. Eating lunch increased the patient's discomfort to a moderate level of pain that seemed to move with the food to the lower portion of his esophagus over a 2 hour period. Finally, an afternoon snack escalated the patient's pain in the upper abdominal region to a severe level. Once again the patient described the pain as following the food as it traveled into the abdominal region. Past Medical and Surgical History: The patient had type 2 diabetes mellitus for approximately 10 years and hypercholesterolemia for at least 27 years. The patient had a hemorrhoidectomy 8 years earlier. Social History: No tobacco use, no alcohol use, and no intravenous drug abuse. Family History: The patient's mother died at age 62 from type 2 diabetes mellitus complications that included 5 years of blindness accompanied by occasional seizures. The patient is a retired civil service employee. Physical Exam and Vital Signs: Upon admission, the patient's temperature was 98.8°F; blood pressure 132/84 mmHg; respirations 18/minute; and pulse 72 beats per minute (bpm). The patient presented with severe epigastric pain with difficulty swallowing, acute localized lower abdomen pain, and a genital rash. He had no signs of blurred vision, sloughing of skin elsewhere on the body, chest pain, coughing, shortness of breath, or abdominal distention. He had no nausea, vomiting, hematemesis, melena, or hematochezia. He had no dysuria or pyuria. He did not have any swelling, ulcers, or numbness in his feet or legs.